Name*:

Phone*:

Email:

Address*:

How long have you lived at this location:

Your date of birth*:

Do you have any roommates or boarders:
YesNo

What are the occupations of all occupants:

Other occupants living in this location (Names/Date of Birth/relation):

Are there any business operations from your location:
YesNo

Are you within 150m or 300m of a fire hydrant:
YesNo

Are you within 5km or 8km of a fire hall:
YesNo

What contents limit would you like coverage for (This is the amount of personal property you own, clothing, furniture, electronics etc.)*:

Style of your home (Detached Home? / Apartment? / Town House? Basement suite?):

Year home was built:

Square footage of your home:

How many bathrooms:

How many stories in the building:

How many units in your complex:

Are there any interior sprinklers in your unit:
YesNo

Have you had any home/tenants insurance in the past?
YesNo

Have you ever been cancelled or refused insurance:
YesNo

Have you had any claims in the last 5-10 years:

Are you part of a union or a member of BC Forum:
YesNo

Additional notes or comments: